AASLD: Fatty Liver in Kids Increases Risks of Death, Transplant

Action Points

Explain to interested patients that non-alcoholic fatty liver disease (NAFLD) has been extensively studied in adults but little is known about the natural history of the disease in children.

Note that this retrospective study suggests the disease, although rare, has serious consequences in children, including a high mortality rate.

Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

SAN FRANCISCO, Nov. 3 -- Children with non-alcoholic fatty liver disease (NAFLD) are more than 13 times as likely to die over a 20-year period or need a transplant as kids in the general population, a researcher said here.

The finding comes from a long-term retrospective cohort study that followed 66 children with the condition for two decades, said Ariel Feldstein, M.D., formerly of the Mayo Clinic in Rochester, Minn., where the study was conducted, and now at the Cleveland Clinic Children's Hospital.

Although the prognosis of the disease has been extensively studied in adults, "these kinds of data are completely lacking in children," Dr. Feldstein said at the annual meeting of the American Association for the Study of Liver Diseases.

To begin to fill the gap, he and his colleagues examined the records of 66 children whose fatty liver disease was confirmed by imaging studies at their institution over the 15-year period from 1985 to 2000. Patient follow-up was extended to April of this year, he said.

The end-points of the study were death or liver transplant.

The average age of the children in the study was 13.9 years, and most were older than 10, he said. Their average body mass index was 31.2, 29% had metabolic syndrome, and 83% had at least one feature of the syndrome, including obesity, hypertension, dyslipidemia and/or hyperglycemia, Dr. Feldstein said.

Most patients had elevated aminotransferase levels, with only 6% of the children having a normal alanine aminotransferase level and 14% having a normal aspartate aminotransferase level.

About two-thirds of the patients showed signs of dyslipidemia, characterized by such things as increased total cholesterol, increased LDL cholesterol, and decreased HDL cholesterol, although fasting glucose was normal in most.

The NAFLD activity score was between three and four in 70% of cases, with an average value of 3.5, Dr. Feldstein said. The score, based on levels of steatosis, lobular inflammation, and hepatocyte ballooning, has a possible high score of eight, indicating the worst level of disease.

At baseline, 40% of patients had no fibrosis, and the remaining 60% had some degree of fibrosis, mainly mild. Only two patients had established cirrhosis, he said.

Those two patients went on to have a liver transplant and two others died of causes judged not to be related to the liver, he said.

Comparison of age- and sex-matched members of the general population with members of the cohort showed that the odds ratio of dying or needing a liver transplant was 13.6, which was significant at P<0.001, Dr. Feldstein said.

He said the main strengths of the study are its relatively large size and long follow-up.

On the other hand, the patients were all seen at a tertiary care center and 80% were white, so the results may not be generalizable to the larger community.

Also, Dr. Feldstein said, only half had biopsies so the researchers were unable to assess the prognostic value of histological factors.

The study is important because it adds to the limited information about the natural history of non-alcoholic fatty liver disease, said Arthur McCullough, M.D., of the Cleveland Clinic.

In adults, studies suggest that up to 20% of those with the condition progress to advanced disease, but "we had no information about children," said Dr. McCullough, who is president of the liver association.

The Mayo study, he said, helps to fill that gap, although the 13-fold increase in mortality is disquieting.

The bottom line, Dr. McCullough said, is that "if you're a child with fatty liver disease, this is not a benign disease."

Dr. Feldstein did not report any external support for the study. He said he had no conflicts.

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